A couple planning a family expects things to take their natural course and for the woman to become pregnant within a few months of saying goodbye to contraception. For many couples this is the case but one in six couples experiences difficulty conceiving a baby. After trying for several more months without success, fertility testing may or may not reveal an underlying problem that can be tackled. Infertility treatment is then worth careful consideration.
In this overview article we look at the full range of infertility treatments available throughout the world; you can follow the links to more detailed articles elsewhere in the guide.
This first category of treatments is the only one that is not classified as assisted reproduction. These infertility treatments aim to treat an underlying problem so that pregnancy can occur naturally:
Surgery to clear a woman’s blocked fallopian tubes: this is done by laparoscopy, and involves only small incisions in the abdomen. Once the tubes are clear, the eggs produced by the ovaries can travel more easily towards the uterus, and a natural pregnancy may be possible.
Hormone treatment to redress an imbalance: this treatment can work well in either partner. Thyroid problems and an imbalance of sex hormones can be corrected by taking artificial hormones.
Correction of an anatomical abnormality: this can include treating a large varicose vein in the testicle that may be blocking sperm release, or correcting retrograde ejaculation (in which the semen goes into the bladder during an orgasm, instead of through the penis).
Surgical sperm retrieval: various surgical methods can be used to extract sperm directly from the testes in men who produce no sperm in their semen. This is generally regarded as being part of assisted reproduction, as the sperm is then used in a cycle of in vitro fertilisation (IVF) with intracytoplasmic sperm injection (ICSI).
Unstimulated IUI or stimulated IUI can be used as a first-line infertility treatment in couples who have unexplained infertility, or where the male partner has a low sperm count or sperm that do not swim too well. Unstimulated IUI involves no hormonal treatments to boost egg production, and introduction of the male partner’s prepared sperm into the uterus is timed to coincide with natural ovulation of a single egg.
In stimulated IUI, the female partner is given hormones to cause multiple eggs to be released, making it more likely that one of them will be fertilised after the male partner’s sperm is introduced.
For couples who cannot or do not wish to use the male partner’s sperm, or for lesbian couples and single women, some countries allow the use of donor sperm in infertility treatments including intrauterine insemination. Often called donor insemination this is done in exactly the same way as IUI (which can be done using stimulation or not) but using carefully screened and selected sperm from a sperm bank.
Gamete intra-fallopian transfer (GIFT) is possible in many infertility clinics around the world but is not done very often. It involves mixing the eggs and sperm together and then placing them immediately back into the female partner, directly into her fallopian tube. If fertilisation occurs, it does so naturally in the woman’s body and so is a more acceptable fertility treatment to many religious groups.
In vitro fertilisation (IVF) is now the most widely used infertility treatment in the world and has produced hundreds of thousands of new human beings, born to couples who would otherwise have been childless.
Standard in vitro fertilisation involves stimulating the production of several eggs, collecting those eggs and mixing them with the partner’s sperm in the laboratory. A high proportion of the eggs are fertilised and embryos are then transferred back into the female partner’s uterus either after 2–3 days or after 5–6 days.
Different countries have different rules on the number of embryos that can be transferred; many are reducing this number to avoid the complication of multiple births
Various IVF options are available:
Natural cycle IVF: no stimulating hormones are used, just the woman’s natural cycle.
Mild stimulation IVF: fewer hormones are used than in standard IVF.
In vitro maturation (IVM): eggs are collected in an immature form from the ovaries, which avoids the use of hormone stimulation but provides several eggs for IVF. The eggs are allowed to mature in culture before sperm is introduced to fertilise them.
For couples in which one partner is not able to offer their own gametes for IVF treatment, a sperm donor or egg donor can be used in some countries. Regulations vary and there are various donor issues to consider, particularly with egg donation as this is a significant procedure for the donor.
The rules surrounding surrogacy the use of a woman to carry a baby for you, with your own eggs, her eggs or those of an egg donor being used with your partner’s sperm or a donor’s sperm, is physically possible using IUI and IVF techniques. It allows a couple to have a child where the female partner is incapable of carrying a pregnancy.
It is, however, fraught with ethical and legal complications, which you need to think about carefully beforehand. Different countries around the world have different regulations on surrogacy and if your country does not allow it, infertility treatment abroad may be your best option.
After IVF, it is possible to select embryos using pre-implantation genetic screening (PGS) or pre-implantation genetic diagnosis (PGD) but this is not allowed in many countries and is very tightly controlled in the ones that do permit it. PGD is usually used to detect the presence of a severe and potentially disabling genetic disease, to avoid it being passed on to a couple’s child.
Some infertility clinics around the world offer immune and anti-coagulant therapy as a way to boost IVF success rates; the evidence for this is limited and the value of such therapy is only established in very specific cases.